Role of platelet rich plasma in management of early knee osteoarthritis pain: A retrospective observational study.

Introduction: Knee joint osteoarthritis is a well-known cause of pain and disability in patients above 40 years of age. It is treated by use of non-steroidal inflammatory drugs, corticosteroids, glucosamine, chondroitin sulfate, physiotherapy with limited success. The platelet rich plasma (PRP) contains a large amount of platelet derived growth factors, cytokines and anti-inflammatory molecules which showed promising results in recent studies to relieve pain of knee joint osteoarthritis. The present study aims to determine the efficacy of intraarticular PRP for pain relief and functional improvement in patients with early knee joint osteoarthritis. Methods: It is a retrospective observation study involving patients who underwent single intraarticular administration of PRP for knee pain with Kellgren-Lawrence (KL) grades I or II knee joint osteoarthritis. The Visual analogue scale (VAS) score and Oxford knee score (OKS) were recorded pre-procedure and at 1- and 6-month post-procedure. Results: A total of 31 patients (20 females, 11 males) underwent PRP therapy for knee pain (16 kL grade I, 15 kL grade II). The mean age and duration of symptoms were of 53.9 years (range: 79-42 years) and 5.53 ± 2.35 years respectively. There was a significant reduction (p < 0.05) in VAS scores from pre-procedure (68.06 ± 8.33) to post procedure at 1 month (37.74 ± 11.16) and 6 months (54.52 ± 11.78). There was also significant improvement (p < 0.05) in OKS score from pre-procedure (31.1 ± 3.47) to post-procedure at 1 month (39.06 ± 3.37) and 6 months (34.10 ± 3.75). No adverse effects were reported in patients during the study period. Conclusion: This small retrospective study suggests that a single administration of intraarticular PRP may be safe and effective for pain relief and functional improvement for up to 6 months in patients of early-stage osteoarthritis.

Evaluation of the role of vertebral augmentation in chronic vertebral compression fractures: A retrospective study.

Objectives: Vertebral augmentation is recommended for acute or subacute vertebral compression fractures (VCFs); few studies claim its usefulness in chronic VCFs also. Use of radionuclide imaging may improvise identification of chronic VCFs that may benefit from vertebral augmentation; hence we have evaluated efficacy of vertebral augmentation procedures in chronic VCFs with incomplete fracture healing suggested either by MRI or Tc99m- MDP bone scan. Materials and Methods: Patients with chronic osteoporotic VCFs (>12 weeks) during the period of June 2013 to June 2019 were included in this retrospective study; patients with evidence of incomplete fracture healing either by MRI or bone scan imaging with Tc 99m-MDP underwent vertebroplasty or kyphoplasty. Primary outcome measure was patient's pain score measured by numerical rating scale (NRS); secondary outcome measures were patient's disability assessed by Roland Morris Disability questionnaire (RDQ); quality of life assessed by Quality of life questionnaire of European Foundation of Osteoporosis (QUALLEFO) and analgesic usage. P â€‹< â€‹0.050 was considered as significant. Results: 34 patients were enrolled for the study with median fracture age of 36 months. The median NRS pain scores, RDQ scores, QUALEFFO scores and analgesic usage were significantly reduced at all-time points as compared to the baseline value over the follow up period of 1 year after vertebral augmentation procedure (P â€‹< â€‹0.050). Cement leakage was seen in 5 patients (15%). Conclusion: Vertebral augmentation procedures provided significant improvements in pain scores, disability and quality of life in patients of chronic osteoporotic VCFs with median fracture age of 36 months.

Comparative efficacy of ultrasound-guided combined suprascapular and axillary nerve block with suprascapular nerve block alone in patients with frozen shoulder: A prospective, double-blinded randomized, single-centre trial.

Background: Frozen shoulder is a troublesome disease of the shoulder joint. It leads to marked disability because of pain with restriction of active and passive movement of the joint. We aimed to determine and compare the efficacy of combined suprascapular and axillary nerve blocks with suprascapular nerve block alone for the treatment of frozen shoulder pain. Methodology: A total of 61 patients with frozen shoulder included in the study underwent ultrasound-guided combined suprascapular and axillary nerve block (n â€‹= â€‹31) and suprascapular nerve block (n â€‹= â€‹30). All the patients were assessed for visual analogue scale (VAS) pain (0-10), simple pain score (0-5), total pain score (0-9), range of motion (abduction, external rotation, and internal rotation) of the affected shoulder joint at baseline and post-procedure at 7 days, 1 month, 3 months, 6 months, and 12 months. Result: There was a significant improvement in VAS pain score, simple pain scores, total pain scores and range of motion of the affected shoulder joint in both groups at all time points as compared to the baseline. However, in the combined nerve block group the VAS scores, simple and total pain scores, abduction, and internal rotation were significantly better at 6 months, 3 months, 6 months, and 12 months, respectively. Conclusion: The combined block provided faster and superior pain relief and improvement in function.

Evaluation of the efficacy of Superior Cluneal Nerve Block in low back pain: A prospective observational study.

INTRODUCTION: Superior cluneal nerve (SCN) entrapment giving rise to low back pain (LBP) remains undiagnosed many times; in this clinical study authors have evaluated therapeutic role of lidocaine injection of SCN for low back pain relief in patients with SCN entrapment. METHODS: The present study was a prospective, observational study; 25 patients with unilateral LBP over the iliac crest and buttock for more than six months not responding to conservative measures were included in this clinical trial. SCN lidocaine injection was done under fluoroscopy guidance; patients having more than 50% reduction in numeric rating scale (NRS) score, for at least 2 h following SCN injection, were enrolled in the study and followed for 6 months. The primary outcome measure was severity of LBP, measured by NRS score. Secondary outcome measures were percentage pain relief; Oswestry Disability Index (ODI) score, reduction of analgesic usage, DSM-IV score for psychological assessment. All these assessments were done prior to the procedure and at 2 weeks, 1, 3 and 6 months after the procedure. RESULTS: A significant reduction in the NRS scores was observed at 2 weeks, 1, 3 and 6 months after SCN lidocaine injection as compared to the baseline (P value < 0.05); authors also observed a significant pain relief and significantly reduced ODI scores, analgesic consumption and DSM scores compared to the baseline values (P value < 0.05). CONCLUSION: A single SCN lidocaine injection provided significant pain relief in LBP patients with SCN entrapment for a period of 6 months.

Evaluation of efficacy of Valsalva for attenuating needle puncture pain in first time nonremunerated voluntary plateletpheresis donors: A prospective, randomized controlled trial.

BACKGROUND: Plateletpheresis is generally safe but may have adverse reactions. Adverse reactions can negatively influence donor recruitment and retention. Valsalva is a proven method of attenuating pain caused by venipuncture. AIMS: The aim was to evaluate the efficacy of the Valsalva maneuver on the attenuation of needle pain and donor anxiety. SETTINGS AND DESIGN: This prospective randomized controlled trial was conducted between November 2015 and April 2016 at the Department of Transfusion Medicine. SUBJECTS AND METHODS: One-hundred and sixty consecutive donors were grouped into control group (C) and Valsalva group (V) each of sample size 80. The Valsalva group performed a Valsalva maneuver and control did nothing before the venipuncture. Anxiety and pain were scored using a 10 cm visual analog scale (VAS). Severity was graded as VAS = 0 defines no pain and anxiety, VAS = 1-3 as mild pain and anxiety, VAS = 4-6 as moderate pain and anxiety, VAS = 7-9 as severe pain and anxiety, whereas VAS = 10 denotes extreme pain and anxiety. STATISTICAL ANALYSIS: Statistical Package for Social Sciences, version 23 was used for analysis. Independent samples t-test/Mann-Whitney U-test was used to compare between treatment and control group, whereas the Wilcoxon signed-rank test was used to test the difference between pre- and postobservations. RESULTS: In the Valsalva group, post-Valsalva anxiety levels were significantly reduced to (1 [0-2]) from their pre-Valsalva values of (2 [0-3]); (P < 0.001). Pain was significantly lower (2[1-2]) in Valsalva group compared to control (4[2-5]); (P < 0.001). CONCLUSIONS: Valsalva reduced both severity of venipuncture pain and anxiety. Valsalva can be performed by donors as it is an easy, painless, and nonpharmacological method of pain and anxiety attenuation.

Prevention of epidural catheter migration: a comparative evaluation of two tunneling techniques.

BACKGROUND: Epidural analgesia failure episodes can be reduced by catheter fixation techniques with a lower incidence of catheter migration. In this clinical study, we compared the roles of two epidural catheter tunneling techniques for the prevention of epidural catheter migration. METHODS: Patients undergoing major abdominal surgery were randomized into three groups of 50 patients each based on the method used to secure the epidural catheter. In the control group (CG), the epidural catheter was secured without tunneling. Tunneling groups 1 and 2 (TG1 and TG2) were defined as tunneling with and without a catheter loop, respectively. The primary outcome measure was the migration of the epidural catheter, while the secondary outcome measures were the adequacy of analgesia and signs of inflammation. All patients were followed up by the acute pain service team twice daily in the postoperative period until the epidural catheter was removed. The results were analyzed by the one-way analysis of variance (ANOVA), chi-square test, and Fisher's exact test. P values <0.050 were considered significant. RESULTS: The three groups were similar with respect to patient characteristics. Catheter migration was significantly reduced in TG2 (two patients) compared to those in the other two groups, i.e., TG1 (eight patients) (P = 0.045) and CG (17 patients) (P = 0.001). No differences were found amongst the three groups in analgesia adequacy and catheter site inflammation (P > 0.050). CONCLUSIONS: Catheter migration was significantly reduced by tunneling without a catheter loop in TG2 as compared to the other two groups. Therefore, we suggest routine use of tunneling without a catheter loop technique in anesthesia practice and look forward to future studies with larger sample sizes.

Evaluation of Serratus Anterior Plane Block for Pain Relief in Patients Undergoing MIDCAB Surgery.

OBJECTIVE: The minimally invasive direct coronary artery bypass (MIDCAB) surgery is associated with severe chest pain in the first 2 to 3 postoperative days; this may delay the patient recovery. In this randomized controlled trial we evaluated the role of serratus anterior plane (SAP) block for postoperative pain relief in patients undergoing MIDCAB surgery. METHODS: Patients undergoing MIDCAB surgery were randomized into 2 groups of 25 each; SAP group received 20 mL of 0.2% ropivacaine with 1 µg/mL fentanyl as bolus followed by infusion at 8 mL/h; control group received saline for both bolus and infusion. Primary outcome measure was postoperative pain when supine, and during deep inspiration, coughing, and patient movement; secondary outcome measures were requirement of postoperative intravenous fentanyl and opioid-related side effects. All patients were followed at 6-hourly intervals for 48 hours in the postoperative period. Results were analyzed by the Student's t -test, χ 2 test, Mann-Whitney U-test and Kruskall-Wallis test. A P-value <0.05 was considered significant. RESULTS: The 2 groups were similar with respect to patient characteristics. Static and dynamic pain visual analog scale scores were significantly reduced in the SAP group as compared to the control group at most of the time points of assessment (P < 0.05). Patient-controlled fentanyl requirements were reduced in the SAP group as compared to control group on the second postoperative day (P < 0.05). CONCLUSIONS: SAP block reduced the postoperative pain scores and opioid requirements in patients undergoing MIDCAB surgery.

Evaluation of efficacy of Valsalva maneuver for attenuating propofol injection pain: a prospective, randomized, single blind, placebo controlled study.

BACKGROUND: Pain on injection is a limitation with propofol use. The effect of the Valsalva maneuver on pain during propofol injection has not been studied. This maneuver reduces pain through the sinoaortic baroreceptor reflex arc and by distraction. We aimed to assess the efficacy of the Valsalva maneuver in reducing pain during propofol injection. METHODS: Eighty American Society of Anesthesiologists class I adult patients undergoing general anesthesia were enrolled and divided into two groups of 40 each. Group I (Valsalva) patients blew into a sphygmomanometer tube raising the mercury column up to 30 mmHg for 20 seconds, while Group II (Control) patients did not. Anesthesia was induced with 1% propofol immediately afterwards. Pain was assessed on a 10-point visual analog scale (VAS), where 0 represented no pain, and 10, the worst imaginable pain, and a 4-point withdrawal response score, where 0 represented no pain, and 3, the worst imaginable pain. Scores were presented as median (interquartile range). RESULTS: We analyzed the data of 70 patients. The incidence of pain was significantly lower in the Valsalva than in the control group (53% vs. 78%, P = 0.029). The withdrawal response score was significantly lower in the Valsalva group (1.00 [0.00-1.00] vs. 2.00 [2.00-3.00], P < 0.001). The VAS score was significantly lower in the Valsalva group (1.00 [0.00-4.00] vs. 7.00 [6.25-8.00], P < 0.001). CONCLUSIONS: A prior Valsalva maneuver is effective in attenuating injection pain due to propofol; it is advantageous in being a non-pharmacological, safe, easy, and time-effective technique.

Comparative Evaluation of Continuous Thoracic Paravertebral Block and Thoracic Epidural Analgesia Techniques for Post-operative Pain Relief in Patients Undergoing Open Nephrectomy: A Prospective, Randomized, Single-blind Study.

BACKGROUND: Open surgical procedures are associated with substantial postoperative pain; an alternative method providing adequate pain relief with minimal side effects is very much required. AIM: The aim of this study was a comparative evaluation of the efficacy of continuous thoracic paravertebral block (PVB) and thoracic epidural analgesia (EA) for postoperative pain relief in patients undergoing open nephrectomy. SETTINGS AND DESIGN: Prospective, randomized, and single-blind study. MATERIALS AND METHODS: Sixty adult patients undergoing open nephrectomy under general anesthesia were randomized to receive a continuous thoracic epidural infusion (Group E) or continuous thoracic paravertebral infusion (Group P) with bupivacaine 0.1% with 1 µg/ml fentanyl at 7 ml/h; both infusions were started after induction of anesthesia. The primary outcome measures were postoperative pain during rest (static pain), deep inspiration, coughing, and movement (getting up from supine to sitting position); the secondary outcome measures were postoperative nausea and vomiting, requirement of rescue antiemetic, hypotension, sedation, pruritus, motor block, and respiratory depression. These were assessed till the morning of the third postoperative day. STATISTICAL ANALYSIS: Results were analyzed by the one-way ANOVA, Chi-square test, and Mann-Whitney U-test. P < 0.05 was considered significant. RESULTS: Both the groups were similar with regard to demographic factors (P > 0.05). The visual analog scale scores at rest, deep breathing, coughing and movement, and postoperative fentanyl consumption were similar in the two groups (P > 0.05); the incidence of side effects was also similar in the two groups (P > 0.05). CONCLUSIONS: Continuous thoracic PVB is as effective as continuous thoracic EA in providing pain relief in patients undergoing open nephrectomy in the postoperative period. The side effect profile of the two techniques was also similar.

Intercostal Neuralgia Occurring as a Complication of Splanchnic Nerve Radiofrequency Ablation in a Patient with Chronic Pancreatitis.

Our intent is to report a case of intercostal neuralgia occuring as a complication of splanchnic radiofreqency ablation (RFA), due to a breach in the integrity of the insulating sheath of the RFA needle.A 48-year-old man presented to our pain clinic with upper abdominal pain due to chronic pancreatitis, recalcitrant to medical management. We decided to perform bilateral splanchnic nerve RFA in this patient. After confirmation of bilateral correct needle placement under fluoroscopic guidance and sensorimotor testing, RFA was performed on the right side uneventfully. However, during RFA on the left side, the patient experienced severe pain in the epigastric region. A bolus of fentanyl 50 µg was given intravenously in order to minimise discomfort, and RFA was performed. In the post-procedure period, the patient described severe pain in the left subcostal and epigastric region, with features suggestive of intercostal neuralgia of the left 11th intercostal nerve. We went back and analysed all the fluoroscopic images again. Convinced of correct needle placement, we examined the RFA needles which had been used for ablation in this patient. One of the needles was discovered to have a fine breach in its insulating sheath, at a distance of approximately 30 mm from the active tip. It is of utmost importance for all interventional pain physicians to perform a thorough pre-use check of the equipment prior to any RFA procedure, with special emphasis on ensuring the integrity of the insulating sheath of the needles which are to be used, in order to prevent injury of non target nerves. KEY WORDS: Splanchnic nerve block, radiofrequency ablation, intercostal neuralgia, radiofrequency ablation complications, radiofrequency equipment check, radiofrequency needle.

Chronic pain in a patient with Ehlers-Danlos syndrome (hypermobility type): The role of myofascial trigger point injections.

Chronic widespread musculoskeletal pain is a cardinal symptom in hypermobility type of Ehler Danlos Syndrome (EDS type III). The management of pain in EDS, however, has not been studied in depth. A 30 year old female, known case of EDS, presented to the pain clinic with complaints of severe upper back pain for 6 months. Physical examination of the back revealed two myofascial trigger points over the left rhomboids and the left erector spinae. Local anaesthetic trigger point injections were given at these points, followed by stretching exercises under analgesic cover for the first week. After 1 week the patient reported 60-80% pain relief. This case highlights that we must keep a high index of suspicion for the more treatable causes of pain like myofascial pain syndrome in patients suffering from EDS, and should address it promptly and appropriately in order to maximise patient comfort.

Fluoroscopic Sacroiliac Joint Injection: Is Oblique Angulation Really Necessary?

BACKGROUND: The conventional technique for sacroiliac (SI) joint injection involves aligning the anterior and posterior aspects of the SI joint under fluoroscopic guidance and then entering the SI joint in the most caudal aspect. OBJECTIVE: We wish to highlight that there is no added advantage to aligning both the anterior and posterior joint lines of the SI joint as it is time consuming, associated with additional radiation exposure, and may make the entry into the posterior SI joint technically more difficult. STUDY DESIGN: Observational study. SETTING: Pain Clinic, Department of Anesthesiology. METHODS: With the patient lying prone on fluoroscopy table, SI joint injection is performed with a 22 G, 10 cm spinal needle in a true anteroposterior (AP) view, where anterior and posterior SI joint spaces are seen as separate entities, where the medial joint space represents the posterior SI joint and the lateral joint space represents the anterior SI joint. The distal 1 cm of the medial joint space is entered under AP view. If the SI joint is seen as a straight line rather than 2 joint spaces in the AP view then the image intensifier of the fluoroscope was tilted cranially to elongate the image of the lower part of the posterior SI joint, thus facilitating entry into this part of the joint which was confirmed by administering 0.3 to 0.5 mL of radiopaque contrast medium. RESULT: Sixty SI joints of 58 patients were injected under an AP fluoroscopic view. Forty-two (70%) SI joints were seen as 2 separate medial and lateral joint spaces and were entered in distal 1 cm of the medial joint space. In 18 (30%) joints seen as a straight line rather than 2 separate spaces, the image intensifier of the fluoroscope was tilted cranially to elongate the image of the lower part of the posterior SI joint and then the SI joint was entered in its distal 1 cm. Confirmation of entry into the SI joint was confirmed by with 0.3 to 0.5 mL of radiopaque contrast medium. In 4 cases the joints did not show the correct radiopaque contrast spread (3/42 and 1/18) although the needle seemed to be in the joint space. LIMITATIONS: Small sample size. CONCLUSION: Aligning the anterior and posterior aspects of SI joint for fluoroscopic guided SI joint injection is not necessary for the success of the block.Key words: Sacroiliac joint, injection, anteroposterior view, oblique angulation, fluoroscopic technique.